A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Monitor oxygen saturation (SpO2) via continuous pulse oximetry.

Observe neck for jugular vein distention.

Notify healthcare provider to prepare for pericardiocentesis.

Assess for paradoxical blood pressure.

Answer and Explanation

The Correct Answer is C

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

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Correct Answer is B

Explanation

A. This statement does not directly address the mother's concern about the progression of CP.

B. Explaining that brain damage with CP is not progressive but has a variable course provides clear and accurate information, reassuring the mother that while the condition itself does not worsen, symptoms and functional abilities may change over time.

C. This option incorrectly suggests that the brain lesion will continue to develop, which is not accurate for CP.

D. This statement provides general information about CP but does not address the specific concern about progression of movement impairments.

A. Urinary meatus. B. The client's bed. C. Catheter tubing. D. Client's bladder.

Correct Answer is C

Explanation

A. The urinary meatus is the external opening of the urethra and is not the source of the infection in this case.

B. The client's bed is not a direct reservoir for the infection, although poor hygiene practices can contribute to contamination.

C. Catheter tubing can harbor bacteria if not properly managed, leading to urinary tract infections. Prolonged periods without proper drainage can allow bacteria to multiply.

D. The client's bladder can become infected due to bacteria introduced via the catheter tubing, but it is not the initial reservoir.

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A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

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A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection. In evaluating the cause of the infection, what should the nurse identify as the infection reservoir?

Correct Answer is C

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